Laparoskopisches „Anoperieren“ von ovariellen Malignomen

Abstract

A controversial discussion has arisen between endoscopists and oncologists about laparoscopic management of ovarian cancer and borderline tumours. A questionnaire was mailed to 273 German Departments of Gyn./Obst. A response rate of 46% (127 hospitals) was obtained concerning the endoscopical technique used, the kind and delay of post-endoscopical cancer operation and the early findings (follow-up) in cases of ovarian cancer, dysgerminoma, malignant teratoma, tubal cancer and borderline tumours of the ovary. In this German survey it could be shown that laparoscopic management of malignant ovarian tumours was not uncommon between 1991-1994. Totally, 61% of ovarian cancer stage Ia and 84% of ovarian borderline tumours stage Ia have been reported without any pathological finding in laparotomy subsequent to laparoscopic management of the lesions. The 192 cases cited here are undoubtedly an underestimate of the real present frequency of endoscopically managed ovarian malignancies. Patients with this early "negative" report should be followed up carefully and may not permit conclusions that laparoscopic management of ovarian malignancies may be harmless for them. In 16% of the stage Ia borderline tumours and in 39% of the stage Ia ovarian cancer early spread has been found totally, demonstrating that implantations and metastases subsequent to the endoscopical procedure can be found even in an early follow-up phase. In 92.4% laparoscopic capsule rupture, tumour morcellement with intraabdominal spilling, subsequent cystectomy or adnectomy had been the technique of choice with additional rinsing of the intraabdominal cavity. This was harmful for the majority of patients if the subsequent cancer surgery by laparotomy was delayed for more than 8 days. Early progression of these cases to stage I c has been reported in 20% (7/36 cases) and to stage II-III in 53% (19/36 cases). Only in 7.4% the endobag procedure was used in laparoscopic management of ovarian cancer stage Ia. In ovarian cancer stage Ic-III (n = 50) an early seeding in the laparoscopic tract was reported in 52% (13/25) if subsequent cancer surgery by laparotomy was delayed more than 8 days. The endoscopical techniques and the early findings after an endoscopical management are reported in detail. In conclusion, in respect of common oncological standards the actual practice in laparoscopic management of ovarian malignancy is considered poor surgery. Capsule rupture, tumour morcellement and unprotected "biopsy" in the intraabdominal cavity and an additional delay of adequate cancer surgery are the main pitfalls of that procedure. For the overwhelming majority of patients undergoing such endoscopical procedures very early implants and metastases in the pelvis, the abdominal cavity or the laparoscopic tract have been found. It seems necessary that laparoscopic management of ovarian malignancies and borderline tumours under the present technical conditions are given up and that we should return to reliable standards of oncological surgery comparable to laparotomy. This should be discussed urgently.